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24
CHAPTER
National AIDS Control
Organization (NACO)
24.1 INTRODUCTION
NACO is the nodal organization for NationalAIDS
response in the Ministry of Health and Family
Welfare. National AIDS Control Programme is a
fully funded Central Sector Scheme implemented
through State/ UTAIDS Control Societies (SACS)
in States/Union Territories (UTs) and closely
monitored through District AIDS prevention and
control unit (DAPCU) in 188 high priority districts.
Currently, National AIDS Control programme
(NACP)-IV (extension) is under implementation
for the period 2017-20.
Components:
A. Prevention: Targeted Interventions (TI) for
High Risk Groups (Female Sex Workers-
FSW, Men who have Sex with Men-MSM,
Injecting Drug Users-IDU, Transgenders
Hijra- TGH) and Bridge population
(migrants, truckers etc) is fundamental
to AIDS response and aims to keep these
population Human Immunodeficiency Virus
(HIV) free through awareness generation,
safe behaviour promotion, HIV testing
etc. Interventions for HIV prevention are
also important for inmates of prisons and
other closed settings. People who have
Sexually Transmitted Infections (STI) have
higher risk of HIV infections and hence the
NACP provides quality standardized STI/
RTI services at Designated STI/RTI Clinic
(DSRC), branded as Suraksha Clinic. Safe
blood (free of HIV, Malaria, Syphilis, Hep
B and Hep C) is ensured through a NACO
supported network of blood transfusion
services.
B. Information, Education and
Communication (IEC): Awareness
generation services were rolled out 25 years
ago with a focus on awareness generation
on the modes of transmission of HIV/
AIDS and the services available for testing
and treatment, and continues to be the
mainstay of NACP through vibrant multi-
media approach comprising Mass media,
mid-media and on-ground mobilization &
Inter Personal Communications across the
country.
C. Testing: NACP provides free HIV
counselling and testing services (HCTS)
for early detection of HIV infections. Free
counselling and testing of pregnant women
are also provided at these facilities towards
prevention of parent to child transmission of
HIV.
D. Treatment: Treatment services offer free
Antiretroviral Treatment (ART) as well
as comprehensive management of HIV
infected people with respect to treatment
and prevention of opportunistic infections.
‘Test and Treat’ policy has been adopted to
enhance the uptake of treatment services
by all irrespective of CD4+ counts. Single
window delivery of TB and HIV services
has also been initiated across all ART
centers. Molecular diagnosis/testing (e.g.
CBNAAT) is being offered to people living
with HIV (PLHIV) identified as presumptive
Tuberculosis (TB) cases for early diagnosis
of TB.
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ANNUAL REPORT I 2018-19
E. Laboratory Services: Quality of testing
under NACP is ensured through laboratory
services through State reference laboratory.
Besides, there are laboratories to monitor
CD4 level among PLHIV in the programme.
Moreover, routine viral load (VL) testing for
all PLHIV on ART has been outsourced to
a private firm. The firm is responsible for
sample collection, VL testing and delivery of
reports. Early Infant Diagnosis is provided
through 6 National Laboratories.
F. Mainstreaming & Partnership and Social
Protection: Mainstreaming & partnership
is one of the key strategies in NACP to
strengthen multi-sectoral response to HIV
and AIDS. Till date, NACO has signed 17
Memorandum of Understanding (MoUs)
with key Ministries/ Departments of Govt.
of India.
G. Strategic Information (SI): NACO
recognizes rigorous and scientific evidence
as central to an effective response and
hence, having a strong SI management was
a high priority agenda under NACP-IV. The
successes of the NACP rest on the bedrock
of evidence that India could generate and
very effectively use, to make critical policy
and programmatic decisions over the last
two decades.
24.2 OVERVIEW OF HIV EPIDEMIC IN
INDIA
As per the recently released, India HIV Estimation
2017 report, national adult (15–49 years) HIV
prevalence in India is estimated at 0.22% (0.16%
– 0.30%) with 0.25%(0.18-0.34) among males
and 0.19% (0.14-0.25) among Females. The adult
HIV prevalence at national level has continued its
steady decline from an estimated peak of 0.38% in
2001-03 through 0.34% in 2007, 0.28% in 2012
and 0.26% in 2015 to 0.22% in 2017.
Among the States/UTs, in 2017, Mizoram has
shown the highest estimated adult HIV prevalence
of 2.04% (1.57-2.56), followed by Manipur
(1.43%, 1.17-1.75), Nagaland (1.15%, 0.92-
1.41), Telangana (0.70%, 0.50-0.95) and Andhra
Pradesh (0.63%, 0.47-0.85). Besides these States,
Karnataka (0.47%, 0.37-0.63), Goa (0.42%,
0.21-0.79), Maharashtra (0.33%, 0.25-0.45) and
Delhi (0.30%, 0.18-0.47) have shown estimated
adult HIV prevalence greater than the national
prevalence (0.22%), while Tamil Nadu (0.22%,
0.14-0.31) had a point prevalence like the national
average. All other States/UTs have levels of adult
HIV prevalence below 0.22%.
The total number of PLHIV in India is estimated
at 21.40 lakhs (15.90 lakhs–28.39 lakhs) in 2017.
Children (< 15 years) account for 0.61 (0.43-0.85)
lakh while female(15+years) accounts for 8.79
(6.61-11.62) lakh PLHIV in India. Among the
States/UTs, in 2017, Maharashtra has the highest
estimated number of PLHIV (3.30 Lakhs, 2.53-
4.35) followed by Andhra Pradesh (2.70 Lakh,
2.00-3.58), Karnataka (2.47 Lakh, 1.91-3.23),
Telangana (2.04 Lakh, 1.49-2.77), West Bengal
(1.44 Lakh, 1.03-1.91), Tamil Nadu (1.42 Lakh,
0.93-1.97), Uttar Pradesh (1.34 Lakh, 1.01-1.77)
and Bihar (1.15 Lakh, 0.83-1.58). These Eight
States together account for almost three fourth
(75.00 %) of total estimated PLHIV. Other all
states have less than 1 lakh people living with HIV.
India is estimated to have around 87.58 (36.45–
172.90) thousand new HIV infection cases in 2017,
showing new HIV infection decline by 85% since
the peak of 1995 and by 27% between 2010-2017.
Women accounted for 40% of annual new HIV
infection in 2017. Annual new HIV infections are
increasing in three States of the North-East Region
- Assam, Mizoram and Meghalaya and also in
Uttarakhand, while in Nagaland, Manipur, Delhi,
Chhattisgarh and Jammu & Kashmir, decline is
less than 10% in last 7 years. Ten States account
for 71% of total annual new HIV infection:
Telangana, Bihar, West Bengal, Uttar Pradesh,
Andhra Pradesh, Maharashtra, Karnataka, Gujarat,
Tamil Nadu and Delhi.
Since 2005, when the number of AIDS related
deaths (ARDs) started to show a declining trend,
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the annual number of AIDS related deaths has
declined by almost 71%. In 2017, an estimated
69.11 (29.94 –140.84) thousand people died of
AIDS-related causes nationally. AIDS-related
deaths have dropped in all of India’s States/UT
with the exception of Assam, Bihar, Jharkhand,
Haryana, Delhi, and Uttarakhand.
India is estimated to have had 22.67(10.92-40.60)
thousand HIV positive women who gave birth in
2017. State wise Prevention to Mother to child
transmission (PMTCT) number were highest in
Maharashtra (2.41 thousand) followed by Uttar
Pradesh (2.29 thousands), Bihar, Andhra Pradesh,
Karnataka, Telangana, West Bengal, Gujarat and
TamilNadu, least being in Sikkim.
Figure 24.2.1: HIV Prevalence (%) among ANC
Client, FSW, MSM, IDU & other risk groups, India
(HSS 2016-17)
24.3 TARGETED INTERVENTIONS
NACO through its NACP aims at halting and
reversing HIV epidemic in India. India’s HIV
epidemic is considered to be concentrated in
nature.
NACO has targeted its preventive efforts towards
sub-groups of population identified to be at high
risk of acquiring HIV infection. These High Risk
Groups (HRGs) include FSW, MSM, Hijra(H)/
Transgenders (TG), IDU and Bridge Populations
such as Migrants and Long Distance Truckers.
They are provided with a number of preventive
services through around 1,443 NGO/CBO led
TIs at present, including; HIV prevention and
screening, treatment, care and support services to
various HRGs. People from high risk communities
are engaged to deliver services and act as catalysts
linking them for services and commodities.
TIprojectsprovideapackageofprevention,support
and linkage services to HRGs through drop-in-
centre (DIC) and outreach-based service delivery
model which includes screening for and treatment
of STI, free condom and lubricant, among core
groups,BehaviourChangeCommunication(BCC),
creating an enabling environment with community
involvement and participation, linkages to
integrated counselling and testing centers for HIV
testing, linkages with care and support services
for HIV positive HRGs, community mobilization,
ownership building and specifically for IDUs, free
distribution of sterile needles and syringes, abscess
prevention and management, Opioid Substitution
Therapy (OST) and linkages with detoxification/
rehabilitation services.
The entire programme is built on the peer led
approach in partnership with NGOs/CBOs
along with SACS and Technical Support Units
(TSU). They extend mentoring, handholding and
technically supporting the TIs for quality service
delivery and enhancing the overall program
performance.
24.3.1 Performance of TI Programme
Coverage of core HRG group: As far as
the coverage of Hijra (H)/ Transgender (TG)
population is concerned, NACO has been making
consistent efforts to scale up the programme and
improve the coverage in high priority States.
Based on the recommendations of Mid Term
Appraisal, option paper developed for TIs, States
were guided to re-structure the TIs keeping in
parameters such as positivity, number of years of
HRG’s association with TI programme, changing
dynamics in sex work and injecting practices, etc.
These strategies will help to enrol new and young
HRGs across typology. TSUs have been directed
to provide on-site assistance and handholding to
revise the outreach plan so as to cover hard-to-
reach and hidden population.
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ANNUAL REPORT I 2018-19
Coverage of Core HRGs (FSW, MSM, IDU and H/TG) (April 2018 to March 2019)
8.68
3.57
1.77
0.70
2.63
(74%)
1.51
(85
%)
0.43
(61%)
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
FSW MSM IDU HTG
In
Lakhs
Estimated Coverage
STI Diagnosed & Treated against Clinic Visit):
As per NACO guidelines every HRGs should visit
STI clinics every quarter, especially for regular
medical check-up and for treatment of STI /
Reproductive Tract Infections (RTI). The clinic
footfall for STI screening was approximately
more than 68% among all core groups, however
STI/RTI cases diagnosed and treated was high
among FSWs as 2.06% while MSM population has
recorded more than 1.16 %. Out of total migrant
provided STI clinical services, 3.5% are having
STI infections; similarly out of total foot fall of
truckers 3.7% found STI infections.
STI Diagnosed & Treated against Clinic Visit in Percentage (April, 2018 to March, 2019)
73
68 69 70
44
64
2.06
1.16
0.35
1.6
3.5
3.7
0
0.5
1
1.5
2
2.5
3
3.5
4
0
10
20
30
40
50
60
70
80
FSW MSM IDU TG Migrant Truckers
Percent
Percent
% Clinic Visit STI Diagnosed & Treated
Source: Monthly Indicator of TI Reporting (MITR) 2019
HIV testing and positivity rate among HRGs:
As per the NACO guidelines, all core HRGs should
be tested for HIV once every six months. The
below figure depicts the percentage of HIV tests
performed among HRGs through referrals from
TI programmes. The positive detection amongst
HRGs has been less than 1.12% and the positivity
recorded 0.22 % and 0.48 % among migrant and
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trucker respectively. The programme statistics
reveals that HRGs who have been associated with
TIs for more than five years have been regular to
testing and keeping consistent efforts to remain
negative across majority of the States. However,
positivity has remained a matter of concern among
IDUs and HTG population. Testing among the
Bridge Population remains a challenge because
of their mobility. Positivity among migrants and
truckers is the same as in last year (0.2%).
HRGs tested for HIV and positivity rate (April, 2018 to September, 2018)
73 71
66
70 67
85
0.13 0.21
1.12
0.59
0.22
0.48
-0.3
0.2
0.7
1.2
1.7
2.2
0
10
20
30
40
50
60
70
80
90
FSW MSM IDU TG Migrant Trucker
Percent
Percent
Axis Title
HIV Testing Positivity
Source: Monthly Indicator of TI Reporting (MITR) 2019
Alive PLHIV (in numbers) HRG currently
registered at ART Centre (Table 24.3.1): Under
the test and treat strategy, all positive HRG should
be on ART. However, 100% achievement is still
not being achieved.
Table 24.3.1: Alive PLHIV (in numbers) HRG currently registered at ART Centre
(April, 2018 to March, 2019)
HRG/Bridge Population PLHIV identified &
registered to ART
Currently on ART Achievement (in %)
FSW 10433 9563 92%
MSM 5451 4888 90%
IDU 6722 5678 84%
HTG 1297 1197 92%
Migrant 3025 2602 86%
Trucker 582 478 82%
Source: Monthly Indicator of TI Reporting (MITR) 2019
Condom distribution among HRGs: Condoms
are distributed to HRGs as per their requirement
through NGOs/CBOs implementing TI
programme. Peer Educators and Outreach workers
engaged in TI programme emphasize on consistent
and correct usage of condoms in all sexual
encounters through one-to-one and one-to-group
interpersonal communication. Fig 24.3.4 shows
the typology-wise number of condoms (free and
social marketing) distributed to the HRGs.
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ANNUAL REPORT I 2018-19
Typology-wise condom pieces distributed to HRGs (April, 2018 to March, 2019)
2077
588
619
117
1630
(79%)
462(79%)
550
(89%)
97
(90
%)
-300
200
700
1200
1700
2200
FSW MSM IDU HTG
In
Lakhs
Demand Distribution
Source: Monthly Reporting of TI Indicators March 2019
Needle & Syringe distribution patterns among
IDUs: As part of the overall Harm Reduction
strategy, to prevent HIV amongst IDUs, free clean
needles and syringes are distributed to IDUs as per
their requirement through NGOs implementing TI
programme. Peer educators at the field as well as at
theDICsandIDUsareencouragedtoreturntheused
syringes and needles, which ensures availability
of sterile syringes and needles and reduces the
possibility of sharing injecting equipment, thus
decreasing risk of HIV transmission and other
blood borne diseases. Programme data shows
that the distribution of needles and syringes to
be consistently high (more than 87%), while the
return rate observed is more than 79%.
Fig 24.3.5: Distribution and Return of Needles & Syringes (April, 2018 to March, 2019)
267.0
348.0
233.0
302.0
185.0
258.0
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
400.0
Syringe Needle
In
Lekhs
Demand Distribution Return
88% 79%
87%
85%
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CHAPTER-24
24.3.2 Opioid Substitution Therapy (OST)
Programme for IDUs
OST was included as a part of the Harm Reduction
package in 2008. India has adopted two model
of OST service delivery: - NGO Model and
Collaborative Model. In collaborative model,
the OST services are being delivered at the
Government Health Facilities in coordination with
the link IDU-TI. There has been massive OST
scale up in India from 56 centres in 2007 covering
5,500 IDUs (approx.) to 212 Stand-alone centres
and 13 Satellite centres currently covering 29,543
active IDUs (approx.) while the overall IDU ever
on OST are more than 70,000.
For providing and assuring quality services, a
continuous process of capacity building is being
followed under OST programme for IDUs. The
operational guideline on OST for clinical staff has
been revised incorporating new development in the
area. A training manual on special needs of Female
Injecting Drug Users (FIDU) has been developed
which aims to address the issues of FIDU. Quality
Assurance Protocol (QAP-Medical) of OST in
India (A reference guide for mentors) has been
developed. The QAP serves as a resource material
for mentors, entrusted with the task of carrying out
periodic ‘Quality Assurance (QA) visits’ to OST
centres.
With the successful implementation of OST, it is
now being recognized as an effective treatment
option under the Narcotic Drug and Psychotropic
Substances (NDPS Amendment Act, 2014). NDPS
allows “management” of drug dependents.
Table 24.3.4: Number of OST Centers FY2018-19 (April, 2018 to Dec, 2019)
State No. of Centers Satellite OST Centre Coverage
Ahmedabad 1 17
Andhra Pradesh 1 116
Arunachal Pradesh 2 123
Assam 2 174
Bihar 2 169
Chandigarh 4 470
Chhattisgarh 4 752
Delhi 11 1 1,802
Goa 1 35
Gujarat 1 35
Haryana 9 1,175
Himachal Pradesh 1 39
Jammu & Kashmir 2 279
Jharkhand 2 61
Karnataka 2 124
Kerala 10 531
Madhya Pradesh 12 1,014
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ANNUAL REPORT I 2018-19
State No. of Centers Satellite OST Centre Coverage
Maharashtra 0 0
Manipur 23 3 2,813
Meghalaya 5 2 726
Mizoram 17 7 2,691
Mumbai 1 65
Nagaland 31 7 3,334
Odisha 4 279
Punjab 30 9,372
Rajasthan 2 165
Sikkim 4 324
Tamil Nadu 1 55
Tripura 3 491
Uttar Pradesh 11 1,465
Uttarakhand 5 493
West Bengal 8 683
All India 212 13 29,989
Source: Monthly Indicator of TI Reporting (MITR) March, 2019
Methadone Based Opioid Substitution
Treatment: The Methadone based Opioid
Substitution Treatment launched at RIMS has
increased the treatment options for people who
inject drugs (PWID). This facility is also available
in Punjab.
Community Based Screening (CBS): As per the
national guideline all the HCTS facilities have been
divided into two types of facilities based on their
services provided for individuals i.e. Screening
facilities & Confirmatory Facility. Hence to ensure
100% coverage of High-Risk-Group for HIV
testing, screening for HIV by TI started CBS in TI
and Link Worker Scheme(LWS). At present 1,150
TIs and 63 LWS started implementing CBS from
FY 2018-19.
States like Delhi, Andhra Pradesh, Rajasthan,
Gujarat and West Bengal started implementing
100% CBS. Approximate 3.2 lakh screenings
were done through core TIs for existing HRG and
7,726 hard to reach HRGs. Approximate 2.6 Lakhs
bridge population was screened through CBS.
Table 24.3.5: Typology wise coverage of Community Based Screening
Sl.
No.
Typology Screened for
HIV
Confirmed
Positive
Linked to ART % of Linked
1 HRG 3,22,062 1,103 959 86%
2 Non-HRG 7,762 111 94 84%
3 Spouses 8,524 65 65 100%
5 Migrant 2,10,356 301 241 80%
6 Truckers 57,415 118 89 75%
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CHAPTER-24
TB Screening & Treatment Cascade: In India,
there are 20.2 Lakh new TB cases annually, with
the highest TB burden in the world. Also, there
is a concentrated HIV epidemic in India which is
focussed only due to its risky behaviour within a
limited population. NACP of India and Revised
National Tuberculosis Programme (RNTCP)
recognized the importance of HIV/TB co-infection
and its control efforts fifteen years back in early
2001. Considering the above, TB screening has
been initiated by TIs in July, 2018; total 24,465
core HRGs and bridge population have been
screened out of which 42,178 were referred for
TB testing, 24,465 were tested for TB and 793
HRGs diagnosed for TB. Total 589 were put on
TB treatment out of 793 diagnosed for TB.
Table 24.3.6: TB Screening and Treatment Cascade (April, 2018 to Mar, 2019)
TB Screening & Treatment FSW MSM IDU TG MIGRANT TRUCKERS Total
a. No. of HRGs Screened for TB 257,852 65,105 49,278 9,326 85,318 12,366 4,79,245
b. Out of a, No. of HRG referred for
TB Testing
18,922 5,003 6,026 1,810 8,820 1,597 42,178
c. Out of b, No. of HRGs tested for
TB
12,056 4,283 2,762 709 4,103 552 24,465
d. Out of c, No. of HRGs diagnosed
as TB
286 126 119 63 179 20 793
e. Out of d, No. of HRGs on TB
treatment
215 84 108 19 149 14 589
Source: Monthly Indicator of TI Reporting (MITR) March, 2019
24.3.3 HIV and TB intervention in Prisons &
other Closed Settings
NACO is implementing HIV/TB intervention in a
phased manner in prisons and other closed settings
in India. While Phases I&II were being stabilised
in North-Eastern (NE) States, Punjab, Chandigarh
and Haryana, Phase-III was observed extensively
across the country during this reporting period.
Based on the direction of AS & DG (NACO), the
intervention has been expanded to Women, living
in Swadhar, Ujjawala and other State-run Homes
in India in close collaboration with Ministry of
Women and Child Development, Govt. of India.
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ANNUAL REPORT I 2018-19
Following were some of the key activities carried
out during this reporting period:
¾
¾ AS & DG, NACO launched HIV/AIDS
intervention programme for women living
in correctional Homes at a function held in
State Home for Women, Guwahati in the
presence of Principal Secretary, Health and
Family Welfare, Govt. of Assam and other
senior officials from line departments.
¾
¾ HIV Prevention, Treatment and Care
Programme in prisons and other closed
settings for Haryana was launched by Shri
K.L. Panwar, Hon’ble Jail Minister, Govt.
of Haryana at a high level meeting held in
Chandigarh.
¾
¾ HIV prevention in prisons and other closed
settings was launched by AS &DG, NACO
in Jaipur in the presence of Additional
Chief Secretary, Health Services, Govt.
of Rajasthan and other senior officials
from State prisons and women and child
development departments.
¾
¾ HIV & TB intervention in prisons & other
closed settings in Madhya Pradesh was
launched by Additional DG, NACO and Shri
G S Meena,Addl. Director General of Prisons
& Correctional Services, Government of
Madhya Pradesh.
¾
¾ HIV and TB Intervention in prisons and other
closed settings in Telangana was launched by
AS & DG (NACO), at a high-level function
held in Hyderabad, in the presence of Deputy
Inspector General of Prisons, Govt. of
Telangana, Director, Department of Women
Development & Child Welfare, Govt. of
Telangana, Project Director, TSACS, Zonal
Director, NCB, Member, Secretary State
Legal Service Authority.
¾
¾ HIV and TB intervention in prisons and
other closed settings in Odisha was launched
by AS & DG (NACO), at a function held
in Bhubaneshwar, in the presence of
Commissioner-cum-Secretary, Department
of Health and Family Welfare, Government
of Odisha, DIG Prisons, Director, Family
Welfare, Deputy Secretary, State Legal Aid
Services.
¾
¾ An inter-divisional meeting was organized
under the chairmanship of AS & DG
(NACO) to enhance synergies between
HIV & TB intervention in prisons and other
closed settings.
¾
¾ A consultation meeting with NCB, MSJE,
BPR&D and UNODC in the context of
drug use & HIV in prisons and other closed
settings was chaired by JS-NACO and JS-
Social Defence Division at NACO. During
the meeting, MSJE informed that the
proposals submitted by State Governments
would be given priority to start the drug de-
addiction centres in prisons.
¾
¾ Three consultation meetings were held
under the chairmanship of AS&DG (NACO)
with key stakeholders in New Delhi. Inputs
received from technical experts have helped
NACO submit to the final draft operational
guidelines on HIV/TB intervention in prisons
and other closed settings which was approved
by AS&DG (NACO) during this reporting
period- the printing and dissemination of the
guidelines is currently in process.
The National Consultation on HIV Intervention
in Prisons and Other Correctional Institutions was
held under the Chairmanship of AS & DG, NACO
in New Delhi.
The commitment to the issue was evident in the
participation of senior officials from: MHA,
MSJE, MoWCD, NCB, Office of Delhi Police
Commissioner, Customs, BPR&D, WHO,
UNODC, USAID, CDC, NICED, NARI, State
Prisons Departments, Social Welfare Dept. and
Dept. of Women and Child Development from
13. 461
CHAPTER-24
differentStates,civilsocietyorganizationsincluding
FHI360, Emmanuel Hospital Associations (EHA),
Solidarity and Action Against HIV Intervention
in India as well as representatives from Swadhar
and Ujjawala Homes and TI-NGOs. The inputs
received from the experts have helped in finalising
the Operational Guidelines for implementing HIV
interventions in Prisons and other Closed Settings
and setting up Surveillance sites in prison settings.
The progress of the intervention is being monitored
using 17 indicators monthly reporting format and
the overall report has been compiled at National-
level. The table given below describes the progress
achieved during the reporting period.
Settings Prisons Swadhar/
Ujjawala
Homes
No. of sites covered 709 45
Total Inmates 3,99,338 1,478
Inmates Tested for HIV 2,27,536 906
Inmates found HIV Positive 3,121 23
Inmates linked to ART 2,651 23
Inmates diagnosed with Hep-C 5,252 1
Inmates on Hep-C Treatment 365 1
Inmates screened for TB 18,712 67
Inmates diagnosed with TB 1,969 3
Inmates on TB -DOTS Treatment 351 3
STI Treated 820 1
A two-day national consultation was organized
with the authorities of police training academies
under the chairmanship of Shri Sanjeeva Kumar,
AS&DG (NACO, RNTCP & CGHS) on 10th
and
11th
of January, 2019 in New Delhi. The National
Consultation was organized by NACO in close
collaboration with Sardar Vallabhbhai Patel
National Police Academy, UNAIDS and UNODC.
The overall objective of the National consultation
Table 24.3.7: Progress of Prison and Swadhar
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ANNUAL REPORT I 2018-19
was to advocate with police training academies to
include topics related to drug use and HIV/AIDS
into their police training curricula.
In his inaugural address, Shri Sanjeeva Kumar,
Additional Secretary & Director General (NACO,
RNTCP & CGHS), Ministry of Health and Family
Welfare, said that the unifying theme for this
initiative is to create awareness about HIV/AIDS
among police personnel. He said NACO is taking
concerted efforts to engage with other agencies in
terms of providing technical support on training
and capacity building to enhance access to various
HIV prevention and treatment services. He had
advised NACO officers to fast-track signing formal
MoUs with key Ministries and Departments to
move forward on this important initiative. He had
reiterated the need to incorporate the experiences
of CBOs and NGOs while finalising the topics on
drug use and HIV for police training academies.
Key achievements (Prisons):
¾
¾ 23 States and 7 UTs have commenced the
implementation of HIV/TB intervention in
prisons
¾
¾ 85% of the HIV positive inmates have been
registered for ART while only 18% of the TB
cases have been linked for treatment
¾
¾ Only 7% of the Hep-C cases were linked for
treatment
¾
¾ 10% -21% of total prison inmates were
identified as drug addicts (% vary across
States –Punjab and NE States reported high
numbers)
¾
¾ Significant number of STI cases were treated
across 7 States (3 UTs & 4 States)
¾
¾ SACS have been requested to liaise with
concerned State TB Officer to make TB
prevention and treatment services available
for prison inmates
¾
¾ It was proposed to establish F-ICTC, ART
and OST in all 139 central prisons. As of
now, only 145 testing facilities (28 ICTC
+ 117 FICTC); 16 Link ART centres;
and 12 satellite OST centres have been
established.
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Key achievements (Swadhar, Ujjawala & State-
run Homes):
¾
¾ HIV/TB intervention launched by AS
& DG, NACO in Assam has paved way
for expanding the intervention to women
living in other closed settings across other
States. CBS, mobile ICTC and health camp
approaches are being deployed for carrying
out HIV testing facilities amongst women.
¾
¾ 100% ART and TB treatment linkages have
been achieved by the team implementing
programmes in homes.
¾
¾ Nine States have commenced the
implementation of HIV/TB prevention
and treatment services in homes and other
States are in the process of rolling out the
intervention.
Based on the guidance of AS & DG (NACO),
majority of the Sates where intervention formally
inauguratedhavesignedMoUbetweenSACS,State
Prisons department and Dept. of Women and Child
Development to ensure effective implementation
of proposed HIV/TB intervention.
Enhancing Partnerships between Law
Enforcement Agencies & Civil Society
Organizations in the Context of Drug Use and
HIV:
The legal and structural barriers continue to
pose huge challenges in reaching out to the most
vulnerable population with HIV prevention and
treatment services. In order to sensitize and forge
partnerships between officials enforcing law;
NGOs implementing TI interventions and senior
officials working with State Health System, a
State-level sensitization workshop was organized
under the chairmanship of AS & DG, NACO in
Guwahati, Assam. There were 7 national-level
consultations held and 36 State/district-level
sensitization workshops were organized through
which more than 1,400 officials were sensitized
on various aspects of drug use and HIV; and
NDPS Act. These workshops provided a stage for
discussion and experience sharing in promoting
partnerships between key functionaries of law
enforcement Agencies (LEA), TI-NGOs and the
State Health Department.
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Other Initiatives under TI
With the cooperation of Development Partners,
bilateral and multilateral agencies NACO is
making concerted efforts to pilot newer initiatives.
Following are some of the key highlights:
a) Sunrise: The Project supports the NACO’s
efforts to curb the epidemic through an
accelerated response of prevention to care
and treatment continuum services among
key populations (KP)/HRG, with a focus
on PWID/IDU. Project Sunrise has been
implementing data-driven and innovative
approaches in collaboration with NACO,
SACS and TI NGOs to accelerate the HIV/
AIDS response to achieve epidemic control.
b) Linkages: ‘Linkages across the continuum
of HIV Services for KPs Affected by HIV
(LINKAGES Project) is to provide Technical
Assistance (TA) for promoting the HIV
cascade of services. LINKAGES in India is
being implemented in six PEPFAR cluster
districtsinstatesofAndhraPradesh(Krishna,
Guntur and East Godavari) and Maharashtra
(Mumbai, Pune and Thane); and providing
support to NACO to strengthen specific
areas of services for KP through innovative
strategies.
c) Cluster Strategy: USAID and CDC in
collaboration with NACO jointly developed
cluster strategy and implementing various
activities to enhance HIV/AIDS Care
Prevention andTreatmentservices at selected
districts. (USAID/CDC through FHI360 and
other development partners).
d) Hridaya: Hridaya is implemented by India
HIV/AIDS Alliance, as a part of Alliance
Integrated Harm Reduction Programme
(AIHRP) of International HIV/AIDS
Alliance Brighton. The Project Hridaya
has been designed to address the capacity
building needs and implementation gaps in
Uttarakhand, Uttar Pradesh and Bihar. More
than 2700 IDUs and 700 of their female sex
partners have been provided with essential
harm reduction services during this reporting
period.
e) Nirantar: Project Nirantar is a civil
society capacity building for advocacy
and response to the HIV/AIDS epidemic
among KPs (FSW, MSM, H/TG and IDU)
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in Chhattisgarh, Madhya Pradesh and
Odisha primarily focusing on building the
local capacity initiatives of TI NGOs and
SACS. The project has built the capacity
of more than 128 TIs through a mentorship
programme; enabled KPs to avail social
protection schemes; sensitized healthcare
providers across facilities at district level;
and obtained community feedback by
deploying community score card approaches
to ensure quality service delivery.
f) Multi-country South Asia HIV program
for MSM & HTG: The regional HIV
programme is to reduce the impact of HIV
on MSM and H/TG in South Asia funded by
Global Fund to FightsAIDS, TB and Malaria
(GFATM) under Round 9. Under the VHS-
MSA DIVA Project during the year 2018 –
2019, the project has capacitated more than
250 TI staff on various components of NACO
TI operational guidelines on HTG people,
sensitised around 100 Government and
key stakeholders on issues affecting HTG
people, advocated with around 600 people at
State and local levels on HIV related issues
affecting HTG people.
g) Community System Strengthening:
NACO is leading a focused initiative on
vulnerability reduction and Community
System Strengthening (CSS) focussing
on CBOs of Andhra Pradesh, Telangana,
Karnataka, Maharashtra and Tamil Nadu for
FSWs program (BMGF through SWASTI).
During the reporting period (January, 2018 to
September, 2018), the project has continued
to provide technical support on vulnerability
reduction services for 64 COs across 5 States
(Andhra Pradesh, Telangana, Tamil Nadu,
Maharashtra & Karnataka).
h) Employer Led Model (ELM): The ELM
has been designed to provide HIV/AIDS
prevention to care services to informal
laboueres including migrants and truckers,
who are linked to the industries directly or
indirectly. Under this model, efforts are made
to involve major industries and associations
to integrate comprehensive HIV/AIDS
prevention to care programme within their
existing structure. MoUs are signed by the
SACS with the respective employers. SACS/
TSU build the capcity of the employers and
support them to conduct different activities
for the informal laboureres. Around 527
MoUs are signed with the industries. The
achivements for MoU signing is 72%. Out
of total MoUs signed, about 444 number
of industries have started implementing
activities for the informal labourers and
around 1.60 lakh informal workers are
covered through the outreach activities.
District AIDS Prevention and Control Units
(DAPCU)
In NACP-III, as a major structural reform, the
management of HIV prevention and control
programme was decentralized to district level.
Using the HIV Sentinel Surveillance data (2004-
2006), all the districts in the country were divided
into four categories (CategoryA, B, C and D) based
on the disease burden. As per this, there were 156
Category A and 39 Category B districts (total 195
districts) across the country that required priority
attention. NACO established DAPCUs in 188
such districts to provide programmatic oversight
through decentralized facilitation, monitoring and
coordination of HIV/AIDS programme activities
in the district.
The major responsibility of DAPCU is facilitation,
monitoring and coordinating NACPactivities at the
district and sub- district level by integrating with
the health system to the extent possible for better
synergy and optimal results. DAPCUs, through
active engagement of the district administration
engages allied line departments and private sector
in mainstreaming the programme and advocates
district-specific initiatives even by leveraging
local resources. This helps in linking vulnerable
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population with various social entitlements and
welfare schemes. DAPCU staff builds the capacity
of the facility staff, monitor the referrals and
linkages through regular supervisory visits to HIV
facilities and monthly review meetings, addresses
supply chain management issues through inter
and intra-district transfers and make troubleshoot
visits, wherever necessary.
AteamofexpertsunderDAPCUNationalResource
Team (DNRT), have been able to continuously
mentor these district level units, at the same time,
have been providing technical assistance at the state
and national level to improve the functioning of
DAPCUs. To promote wider sharing of knowledge
within the districts, different platforms have been
created. One of them is identification of successful
approaches and models, documenting them as
case studies and sharing them widely with all the
DAPCU staff in the form of “DAPCU Series”.
This practice has encouraged many DAPCUs
to document and present their achievements to
SACS and NACO through DAPCU series. While
it is difficult to include all the experiences through
this mode, the need for a larger space was felt.
“DAPCU SPEAK” (http://dapcuspeak.blogspot.
in/), is another initiative that emerged from this
experience. This helps in peer learning and gradual
building of knowledge in the field staff, if used
properly.
Link Worker Scheme (LWS) - Reaching-out to
Rural Populations
In fourth phase of NACP, the LWS has been
designedtointensifyandconsolidatetheprevention
services focusing on risk population in the rural
areas with a mandate to work in 128 districts across
16 States of India in the FY 2018-19. Two districts
are withdrawn since last year. The LWS aims to
address complex needs of rural HIV prevention,
care and support through identification and training
of village level workforce of Zonal Supervisors,
Cluster Link Workers and other stakeholders on
issues of HIV/AIDS, gender, sexuality and Sexual
Tract Infections.
The scheme envisages creation of demand for
various HIV/AIDS related services, linking of
the target population to existing services (as
the scheme itself does not create any service
delivery points), creating an enabling and stigma
free environment, ensuring the target population
continue to access information, services in a
sustained manner, creating linkages with services
of other departments through ASHA volunteers,
anganwadi workers, panchayat heads etc.
The scheme involves highly motivated and trained
community members – 20 Cluster Link Workers
in each district for clusters of villages (usually
5 villages each) – responsible for establishing
linkages between the community on one hand
and information, commodities and services on the
other. These Cluster Link Workers are supervised
by 2 Zonal Supervisors in each district.
The specific objective of the scheme includes:
Reach out to HRGs and vulnerable men and women
in rural areas with information, knowledge, skills
on STI/HIV prevention and risk reduction. This
entails: (a). Increasing the availability and use
of condoms among HRGs and other vulnerable
men and women. (b). Establishing referral and
follow-up linkages for various services including
treatment for STIs, testing and treatment for TB,
ICTC/PPTCT services, HIV care and support
services including ART, (c). Creating an enabling
environment for PLHAand their families, reducing
stigma and discrimination against them through
interactions with existing community structures/
groups, e.g. Village Health Committees (VHC),
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Self Help Groups (SHG) and Panchayat Raj
Institutions (PRI).
LWS Progress in FY 2018-19
In FY 2018-19, LWS was proposed to be
implemented in 128 districts across 16 States. As
on March, 2019, LWS was implemented in 121
districts. Under the scheme, over 50,311 FSW,
4,121 IDUs, 5,100 MSMs and 226 TGs were
reached in rural areas nationally. In addition to this,
the scheme also covered nearly 5.0 lakh migrants,
0.78 lakh truckers and 6.4 lakh other vulnerable
populations. The programme also reached out to
21,637 PLHIV; 1.4 Lakh ANC and around 12,559
TB cases. Around 8.8 Lakh population were tested
for HIV; and 41,907 cases have sought treatment
for STI. The above services were provided by
establishing linkages with existing services.
60,04,025 free condoms and approximately
6,75,112 socially marketed condoms were
distributed during the period.
Condom Promotion Programme
Condom promotion by the MoHFW, Government
ofIndia(GoI)hasalonghistory.Intheinitialperiod,
condom was promoted under National Family
Planning Program. With the emergence of HIV as
a serious health threat, promotion of condom for
preventing HIV/AIDS was taken under the NACP.
With the knowledge that maximum percent of
HIV infection is transmitted through unsafe sex,
significant efforts have been made by NACO to
increase the awareness and usage of condoms to
prevent the transmission of HIV/AIDS. NACP
has consistently focussed on prevention from
HIV/AIDS through safe sex practices. Given the
significant role of condoms in the prevention of
STI/HIV infections, the NACO promotes condom
use for controlling the epidemic.
In view of the prevailing status regarding condom
usage in the country, a well-focussed national
level condom programme has been implemented
that includes distribution of free condoms among
the most vulnerable ones. The desired behavioural
outcomes of the condom programme are to increase
consistent use of condoms among men with the
non-regular sexual partners or in commercial
sex encounters and among married couples for
preventing unwanted pregnancies.
Condom Demand Generation
NACO continued to follow its communication
framework devised under the current strategy
adopted for long term that is based on promoting
condom use by enhancing self-risk perceptions.
The primary objective is to motivate the behaviour
change among the key target population like HRGs,
bridge population as well as general population
especially the youth as a category. Under this
strategy, all condom promotion communication
activities were developed to focus on bringing
positive behaviour change towards consistent
condom use. These promotions are designed
to promote condoms for its benefits of triple
protection from the risks of HIV/AIDS, STI and
unwanted pregnancy.
NACO promotes safe sex and regular condom
use through its campaigns on mass media.
These condom promotion campaigns on mass
media are aired on national networks of Door-
darshan, leading Cable & Satellite Channels, All
India Radio and private FM channels to ensure
countrywide footprints. This year, a new mass
media campaign was developed in Hindi and other
regional languages.
The new campaign is based on theme of ‘making
regular condom use a habit’to ensure its consistent
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ANNUAL REPORT I 2018-19
use. The basic premise of this communication is to
encourage audience to adopt safe sex practice by
using condom every time. This campaign has been
developed in two parts depicting various common
incidents and events occurring in daily life of a
lay man. The essence of each of these episodes
is to highlight benefits of good habits and thus
appealing for making condom use a habit in order
to play safe while having sex. This campaign was
conceived to be an integrated one encompassing
compatibility across various media platforms
including television, radio, outdoor, social media
sites on the internet, mid-media activities, leaflets
and merchandise as promotion material for display
at the points of purchase. Digital cinema screening
was also included in condom campaign; media
plan to reach out to the target population through
cinema halls of smaller towns. Only those cinema
halls located in priority districts are shortlisted.
Free Supply of Condoms
Condom programme implemented by NACO
focuses on optimizing the supply of free
condoms to ensure availability to the vulnerable
population and minimize the wastage of free
condom. The institutional mechanism has been
established to regularly track, free condom supply
received from Ministry of Health & Family
Welfare to SACS to avoid stock out situation
at SACS; to analyse free condom from SACS
to TI-NGOs and subsequent distribution from
various TI-NGOs to Most at Risk Populations
(MARPs); and estimate free condom demand at
TI-NGO and SACS levels based on previous data
analysis. The annual condom demand is estimated
at SACS based on HRGs coverage, past condom
usage trends and reviews of existing inventory
of free condoms at SACS as well as at TI-NGOs
covered by SACS. NACO in close collaboration
with respective SACS ensures availabilities of free
condoms under National Health Mission (NHM)
and stocks are transferred from NHM to SACS
wherever feasible. Based on the budget available
with NACO, below is the State wise supply of free
condoms in FY 2018-19:
Table 24.3.8: Free Condom Estimation under
NACO for 2018-19
States Estimated
Annual Demand
of Free Condoms
Total Supply
Ahmedabad 2,412,000 2,050,000
A&N Islands -
Andhra Pradesh 47,046,960 43,412,900
Arunachal
Pradesh
444,000 450,000
Assam 5,412,000 5,500,000
Bihar 5,304,528 3,000,000
Chandigarh 2,418,000 2,000,000
Chhattisgarh 9,000,000 8,200,000
Dadar& Nagar
Haveli
14,400 100,000
Daman & Diu 390,000 400,000
Delhi 24,948,000 21,118,950
Goa 1,680,000 1,500,000
Gujarat 12,384,000 11,800,000
Haryana 4,848,000 4,700,000
Himachal
Pradesh
1,801,452 1,700,000
Jammu &
Kashmir
250,000
Jharkhand 1,200,000 1,000,000
Karnataka 27,186,492 26,000,000
Kerala 4,920,000 4,025,000
Lakshadweep 50,000
Madhya Pradesh 7,200,000 6,300,000
Maharashtra 60,600,000 56,000,000
Mumbai 12,000,000 11,000,000
Manipur 3,600,000 3,200,000
Meghalaya 369,600 250,000
Mizoram 999,996 328,727
Nagaland 2,078,136 1,850,000
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States Estimated
Annual Demand
of Free Condoms
Total Supply
Odisha 6,564,000 5,900,000
Punjab 4,343,796 4,200,000
Puducherry 1,020,000 900,000
Rajasthan 6,660,000 5,500,000
Sikkim 244,440 500,000
Tamil Nadu 18,763,500 18,000,000
Telangana 28,788,600 22,807,678
Tripura 1,080,000 600,000
Uttar Pradesh 16,018,200 15,192,313
Uttarakhand 1,800,000 1,400,000
West Bengal 4,324,632 3,600,000
Total 327,864,732 294,785,568
24.4 SEXUALLY TRANSMITTED INFECTIONS
(STI) AND REPRODUCTIVE TRACT
INFECTION (RTI) CONTROL &
PREVENTION PROGRAM
The prevention and control of STIs is a well-
recognised, cost effective strategy for controlling
HIV transmission and reducing reproductive
morbidity. Early diagnosis; appropriate and
complete treatment of STI/RTI reduces the
transmission rate of HIV infection by more than
40%. Syndromic Case Management (SCM), with
minimal laboratory tests is the cornerstone of STI/
RTI management under NACP. The key strategies
for STI prevention and control are to (a) interrupt
transmission where it spreads fastest, and (b)
provide services for all who may need them.
Currently, there are 1,165 NACO supported DSRC
across the country (at least one DSRC per district).
There are two arms of DSRC are a) Obstetrics &
Gynaecology OPD and b) STI OPD under dermato-
venereology clinics and provide services through
existing public health care delivery system.
The details of number of individual availed STI
service and diagnosed STI and pregnant women
tested for Syphilis and diagnosed syphilis during
FY 2017-18 and FY 2018-19 (from January, 2018
till March, 2019 along with North –East data), are
provided in the following table.
Table 24.4.1: STI/RTI Testing and sero-prevalence
FY No. of
Individual
availed RPR/
VRDRL
Service
No of
Individual
Reactive
No. of
Individual
referred to
ICTC for
HIV test
No. of
Individual
Found
HIV
positive
Total ANC
registration
reported
in STI/RTI
centre
No. of PW
tested for
Syphilis
No. of
PW
found
Syphilis
reactive
No. of
PW
Treated
for
Syphilis
2017-18 40,21,460 16,863
(0.4%)
36,77,932 15,840
(0.43%)
44,98,740 36, 80,696
(82%)
3946
(0.11%)
1882
(48%)
2018-19* 5036552 21734
(0.43%)
4602583 18179
(0.39%)
5670876 4685829
(82.64%)
5073
(0.10%)
2591
(51.07%)
(* from Jan, 2018 till Mar, 2019)
The sero prevalence of Syphilis is observed to be
declining steadily among patients with STI/RTI,
pregnant women and HRGs.
NACO target is to manage 94.8 lakh episodes of
STI/RTI in 2018-19, out of which the program has
achieved 88.35 lakh (93%) till March, 2019.
Pre-packed STI/RTI colour-coded Kits
The colour coded STI/RTI kits have been provided
for free supply at all DSRCs and TI NGOs to
standardize the treatment. The pre-packaging of
the drugs is being recognized as one of the global
innovation in STI programme management. The
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ANNUAL REPORT I 2018-19
drugs used to treat common STI/RTI are included
in the National/State List of Essential Drugs.
The division also procured Injection Benzathine
Penicillin 2.4 million units for all health facilities
including NHM facilities.
Regional STI/RTI Training, Research and
Reference Laboratories
There are 10 functional Regional STI Training,
Reference and Research Laboratories supported &
strengthened by NACO. These are located at :
1) Osmania Medical College, Hyderabad
2) Medical College Kolkata and Institute of
Serology, Kolkata
3) Government Medical College, Nagpur
4) Government Medical College, Baroda
5) Institute of Venereology, Chennai
6) Maulana Azad Medical College, New Delhi
7) BYL Nair Hospital, Topiwala National
Medical College, Mumbai
8) Government Medical College, Guwahati,
Assam
9) Post Graduate Institution of Medical
Education and Research, Chandigarh
10) Safdarjung Hospital, New Delhi which acts
as the Apex Centre as well as Regional
Laboratory for the country.
The key functions of these laboratories are to
provide etiologic diagnosis of common STI/RTI
syndromes, validation of syndromic diagnosis,
monitoring of drug sensitivity of gonococci and
implementation of Syphilis External Quality
Assessment Service (EQAS).
NACO and CDC with SHARE India have
conducted assessment of all the Regional STI
Centre last year, during assessment of Quality
management system and programme component.
During the period May-August, 2017, Apex
Regional center, (Safdarjung Hospital) has
conducted STI Surveillance and community
based study in HRGs to find out the Susceptibility
&Sensitivity Pattern of Gonococci (GASP), first
line drug used for the Gonorrhoea.
Training and Capacity building and regular onsite
mentoring of STI/RTI service providers.
Standardized training curriculum for doctors, staff
nurse, laboratory technician and counsellor is in
place. The training to these staff is provided in a
cascade form through a cadre of national, State and
regional resource faculties across all States. All
faculty members have been trained using the same
trainingmaterial,followingadultlearningmethods.
The State and regional resource faculties in turn
have conducted training of STI/RTI clinic staff in
the designated clinic and TI NGO. Additionally,
each district has district resource facilities for
training doctors, nurses and laboratory technicians
on STI/RTI management for sub district health
facilities (PHC, CHC, and Sub –district hospital),
and doctors in private sector also.
Basics of STI programme activities were included
in the curriculum developed for trainings of
ANM at FICTC and laboratory technicians of
ICTC, wherein the related curriculum has been
incorporated into their existing curriculum so as to
make service delivery comprehensive. To enable
screening of pregnant women accessing labour
room directly, a training module was designed to
orient labour room nurses for screening of direct
walk in pregnant women both for HIVand Syphilis.
Convergence with NHM
STI/RTI services are also an integral part of
services provided at all Government health
facilities including PHC/CHC. At each of these
health facilities a standardized service delivery
protocol is followed. Medical and paramedical
staffs are trained, free STI treatment is provided to
patients and monthly reports on STI/RTI indicators
23. 471
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are reported by these facilities through existing
HMIS.
In addition of earlier indicators, the following
indicators of Syphilis have been incorporated in the
Health Management Information system (HMIS).
1. Number of PW tested using POC test for
Syphilis
2. Out of above, number of PW found sero-
positive for syphilis
3. Number of pregnant women tested for
Syphilis
4. Number of pregnant women tested found
sero-positive for Syphilis
5. Number of syphilis positive pregnant women
treated for Syphilis
6. Number of babies diagnosed with Congenital
Syphilis
7. Number of babies treated for congenital
Syphilis
National operational guidelines and training
modules for medical officers and para-medical staff
for STI/RTI services have been developed jointly
by NACO & NHM and disseminated. A joint
convergence meeting between NACO and NHM
is conducted once every quarter. STI curriculum is
integrated in the training module for nurses and an
integrated package of STI/HIV training is imparted
by Indian Nursing Council for nursing staff as per
the standardized curriculum.
NACO has revised national STI/RTI technical
guidelines, 2014 in consultation with NHM. STI
Division and NHM are jointly implementing
Elimination of Parent to Child Transmission
(EPTCT) of Syphilis and has done joint
procurement of Inj. Benzathine Penicillin for
NHM.
Provision of STI/RTI Services in HRG
Population
The provision of a standardized package of STI/
RTI services to HRG population is an important
component of the TI projects. All the core group
population receives packages of services which
include:
1. Free consultation and treatment for
their symptomatic STI complaints
2. Quarterly medical check-up
3. Asymptomatic treatment (presumptive
treatment)
4. Bi-annual syphilis and HIV screening
Preferred Private Provider approach has been
rolled out to scale up STI/RTI services to HRG
population under TI Projects. These providers
are selected by the community members through
group consultation. This approach has enhanced
access to services for the HRG. Under this
approach, all the HRG receives free STI/RTI
treatment and the providers receive a token fee of
Rs.75 per consultation. A total of 3400 preferred
providers are providing STI/RTI services to the
HRG. All these preferred providers are trained
using a standardized curriculum on syndromic
case management. Colour coded STI/RTI drug kits
have also been made available to these providers
for free treatment of sex workers, MSM and
IDU, and data collection tools are also provided
to them.
Partnering with PSU and Professional
Organization
The major proportion of patients with STI/RTI seek
services from the vast network of private health
care delivery systems ranging from freelance
private practitioners to large public hospitals.Also,
many populations are accessing services from
public health care systems under other sectors like
railways, ESI, Armed Forces, CGHS, Railways,
Port hospitals as well as health facilities of public
sector undertakings like Coal India Ltd, SAIL
etc. It has been felt that reaching out to maximum
number of people suffering from STI/RTI is not
possible without partnership with private sector
and organized public sector. NACO has initiated
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ANNUAL REPORT I 2018-19
partnership with organized public sector and
private sector through professional associations to
support the delivery of STI/RTI services with the
objective to reach the populations presently not
covered by the public health care delivery system.
STI/RTI services have been rolled out in major
port hospitals, ESIC, private medical colleges.
National Strategic Plan 2017-2024 (NSP)
The vision of STI/RTI control and prevention
program is to provide standardized STI/RTI
services and Sexual and Reproductive Health
services (SRH) at all levels of health system
through convergence with NHM and private
sector; especially focusing on women, adolescent
and marginalized population.
The strategies propose to provide comprehensive
STI/RTIservicesnotonlytovulnerablepopulations
and HRGs but also to the general population and
communities at large. In doing so, NACO will
ensure greater convergence and ownership of STI/
RTI management in the general health system and
partnership with private sector.
24.5 BLOOD TRANSFUSION SERVICES
The annual requirement of blood for the country
is estimated at 1.5 crore units of blood and the
endeavour is to meet the blood needs of the country
through voluntary non-remunerated donation
through a well-coordinated and networked blood
transfusion service.
Blood Transfusion Services (BTS)
The BTS comprise of 3,108 licensed blood banks
across all states and sectors, of which a network of
1,131 blood banks are supported by NACO in the
way of equipment, manpower and consumables.
Overall 75.05% of blood was subjected to
componentization in NACO supported Blood
Component Separation units in 2018-19.
NACO has been primarily responsible for ensuring
provision of safe blood for the country since 1992.
During NACP, the availability of safe blood
increased from 44 lakh units in 2007 to 1.22 crore
units by 2018-19. During this phase, incidence of
donor HIV sero-reactivity has declined from 1.2%
to 0.14% in NACO supported blood banks.
Table 24.5.1: Blood Donation statistics for Blood Transfusion Services, India
Financial Year 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19
Total Collection(in Millions) 9.8 9.95 10.83 10.8 11.09 11.45 12.20
Collection in NACO supported BB
(in millions)
5.48 5.76 6.64 6.3 6.6 6.9 7.2
Voluntary Blood Donation in
NACO supported BB (%)
84 84 84 79 77 78 76
HIV (%) 0.2 0.2 0.14 0.14 0.12 0.13 0.14
HBsAg (%) 1.1 1 0.85 0.86 0.92 0.89 0.78
HCV (%) 0.4 0.4 0.33 0.34 0.3 0.29 0.33
MP (%) 0.1 0.1 0.08 0.07 0.05 0.07 0.05
VDRL (%) 0.2 0.2 0.18 0.15 0.21 0.18 0.23
Component Separation in NACO
supported BCSU
- 58.70% 61.60% 69% 68% 71% 75.05%
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During the FY 2018-19, 70.2 lakh blood units
were collected across the country in NACO
supported blood banks. 76.30% of the collection
was through voluntary blood donation (VBD).
The VBD percentage is comparatively lower than
the previous years due to a change in definition
of voluntary blood donor, so as to exclude family
donors.
Key Strategies:
Government has adopted a comprehensive
approach towards strengthening BTS, key
strategies for which include:
• Increasing regular voluntary non-
remunerated blood donation to meet the
safe blood requirements of safe blood in the
country;
• Promoting component preparation and
availability along with rational use of blood
in health care facilities and building capacity
of health care providers to achieve this
objective;
• Enhancing blood access through a well
networked regionally coordinated BTS;
• Establishing Quality Management Systems
to ensure safe and quality blood and
• Building implementation structures and
referral linkages.
National Blood Transfusion Council (NBTC)
The functions of NBTC as the policy formulating
apex body in relation to all matters pertaining to
operation of blood centers are as follows:
• Commitment to provide safe and adequate
quantity of blood, blood components and
blood products through an organized blood
transfusion service in the country;
• Formulate and implement National Blood
Policy and implement National Blood
Programme in the country; Make latest
technology available for operating the
BTS and encourage the appropriate use of
blood and blood product and encourage the
researchanddevelopmentoffieldtransfusion
medicine and related technology
• Take adequate regulatory and legislative
steps in blood transfusion process and
provide adequate resource policy framework
of blood bank services in the country.
NBTC and State Blood Transfusion Council
(SBTC) are the apex bodies responsible for BTS at
national and state level.
Activities of NBTC in 2018-19 include:
1. EQAS through two Proficiency Testing
providers @ Rs. 4,000 per blood bank per
year for
a) 179 blood banks through CMC,Vellore
completed
b) 189 blood banks through SDMH,
Jaipur Completed
2. Review meeting of SACS/SBTC and RTC
held in March, 2018
3. Dissemination of report of National Study
on Blood Requirement in India
4. TRG meeting held in May, 2018
5. Draft document of BB and BTS Standards
submitted to TRG for review
6. Observance of World Blood Donor Day
through a month long campaign
7. Nation-wide VBD drives in partnership with
Akhil Bharatiya Terapanth Yuvak Samiti,
TCIF, NTR trust, Rotary Club
8. First meeting of Standing Committee of
NBTC under the chairpersonship of JS
Policy, MOHFW on 27th
June, 2018
9. First meeting of Expert Working Group for
VBD Guidelines held on 28th
June, 2018
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ANNUAL REPORT I 2018-19
10. Dissemination of revised Manpower Norms
for blood banks with recommendation to
DCG(I) for regulatory amendments
11. MoU withAATM for conduction of trainings
for private sector blood banks
12. National Review Meeting for Regional
Training Centres and curriculum review in
September, 2018
13. Expansion of pool of master trainers for
counselling blood donors in September,
2018
14. Review and revision of specifications of
blood bags to include triple blood bags with
SAGM and diversion pouch in triple and
quadruple blood bags.
15. Review and revision of specifications of
testing kits to include IVth
generation kits for
HIV ELISA, HIV Rapid and HCV ELISA.
16. Recruitment against vacancy of Programme
Officer QC
17. Training of the Technical Officers for lab
services and blood bank conducted in NACO
HQ in March, 2019
18. Joining of Medical Officer with Pathology
qualification through detailment from CGHS
19. Development of Mobile app for NBTC,
security audit and upgradation of NBTC
website.
27. 475
CHAPTER-24
Promotion of Voluntary Blood Donation
Special days such as World Blood Donor Day and
National Voluntary Blood Donation Day were
observed at national and state level recognizing
the contribution of repeat non-remunerated repeat
voluntary blood donors.
Logo and tagline for VBD has been developed
(Raktdaan, Karke Dekho, Achcha Lagta Hai). It
will be used extensively in all the IEC Material
developed and will give a separate entity to VBD.
IEC material has also been created which consists
ofposters,leaflets,standees,corporatedocket,short
movie and exhibition panels. These IEC Material
was developed by taking inputs from central &
State officers of BTS, VBDs, SACS Youth and
IEC officers along with field experts in transfusion
medicine, blood donor counselling, blood donor
motivation and recruitment and representatives of
NGOs engaged in promotion of VBD.
Communication Strategy has also been developed
to support the optimal use of IEC materials.
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ANNUAL REPORT I 2018-19
24.6 BASIC SERVICE DIVISION (BSD)
The BSD of the NACO provides HCTS for HIV
infection, the first critical step in detecting and
linking people with HIV to access treatment
cascade and care. It also provides an important
opportunity to reinforce HIV prevention. The
national programme is offering these services
since 1997 with the goal to identify as many
people living with HIV, as early as possible (after
acquiring the HIV infection), and linking them
appropriately and in a timely manner to prevention,
care and treatment services. The introduction of
ART services for people living with HIV/AIDS in
2004, gave a major boost to counselling and testing
services in India.
The HCTS include the following components:
• Integrated Counselling and Testing Centres
(ICTC)/HCTS
• Prevention of Parent-To-Child Transmission
of HIV (PPTCT)
• HIV/TB collaborative activities
A. Integrated Counselling andTesting Centre
(ICTC)
There are different types of HCTS facilities in
India, which include Standalone ICTC (SA-ICTC),
Mobile ICTC, Facility Integrated Counselling
and Testing Centres (F-ICTCs), Public Private
Partnership ICTCs (PPP ICTCs), and CBS for HIV
including Village Health Nutrition Day (VHND).
The terminology of ICTC becomes HCTS Centre
after the release of National HCTS Guideline Dec
2016. In order to offer HIVtesting to every pregnant
woman in the country, so as to enhance detection
of all HIV positive pregnant women and eliminate
transmission of HIV from parent to child. There is
an increase in the number of ICTCs in the country,
clearly portraying integration of counselling and
testing services under general health services,
increase in geographical coverage of these
services below block level, better accessibility and
addressing sustainability.
29. 477
CHAPTER-24
Scale-up of ICTCs during the period from 2007-08 to 2018-19
4,567 5,027 5,210 5,239 4,533 4,508 4,818 5,347 5,521 5,545 5,546 5,412
1,270 2,302 5,018 16168
8,811
10,645 12,067 13,243
16,168 18,228
964
3780
1,977
2,377
2,465
3,434
3,780
4,283
2,054
0
5000
10000
15000
20000
25000
30000
35000
2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19
Number
Year
Stand Alone ICTC F-ICTC PPP-ICTC CBS
(data (provisional) source is Strategic Information Management System (SIMS) as on March, 2019
and the cumulative data since April, 2018 –March, 2019 has been taken)
HIV Counselling and Testing Services of
General Individuals
During the FY 2017-18, around 209.9 lakhs
general individuals were tested for HIV out of
against the annual target of 180.7 lakhs and out of
which 182,397 general individuals were diagnosed
HIV positive. While, during Jan, 2018 to March,
2019, around 308 lakhs general individuals have
been tested for HIV, out of which 2,21,428 were
diagnosed HIV Positive. The below Figure shows
year wise general individuals tested for HIV and
the positivity.
Scale-up of General Individuals tested and positivity in ICTCs
during the period from 2007-08 to 2018-19
(data (Provisional) source is SIMS as on 22nd
April, 2019 and the cumulative data for Jan, 2018 to March,
2019 has been taken)
56
83 90
109 104
130
150
165
186
210
309
5.0
3.6
3.2
2.5
2.2
1.8
1.4
1.2
1.0 0.9
0.7
0.0
1.0
2.0
3.0
4.0
5.0
6.0
0
50
100
150
200
250
300
350
2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 Jan.2018
to Mar
19
Positivity
(%)
Number
Tested
(in
Lakhs)
Years
General Individual Tested (In Lakhs) Positivity (in %)
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CHAPTER-24
ANNUAL REPORT I 2018-19
B. PreventionofParenttoChildTransmission
of HIV (PPTCT)
The PPTCT programme was started in the country
in the year 2002.As on 2019 March, 29,977 ICTCs
in the country offer PPTCT services. The aim of
the PPTCT programme is to offer HIV testing to
every pregnant woman (universal coverage) in the
country, so as to cover all estimated HIV positive
pregnant women and eliminate transmission of
HIV from mother-to-child. During the FY 2015-
16, NACO has decided to implement Early Infant
Diagnosis(EID) service through all SA-ICTCs
(fixed) across the country. Currently this service is
available through all (5,412) SA-ICTCs.
In the FY 2017-18, against the target of 180.7 lakhs
pregnant women, 207.7 lakhs were tested for HIV.
Out of which, 9,550(new cases) pregnant women
werefoundHIVpositive.Therewere4,792*known
HIV positive Pregnant women were also reported
in FY 2017-18. Out of total (new +known) 14,342
HIV positive pregnant women, 93% (13,276) were
registered at ART and 91% (13,027) were initiated
lifelong ART. Further HIV exposed live birth
reported in 2017-18 is 11,409 out of which, 87%
babies were initiated ARV prophylaxis.
During the period of January, 2018 to March,
2019, around 274 Lakhs of pregnant women were
tested** for HIV, and total 18,240 (11,839 new
cases & 6,401 known cases*) HIV positive cases
were reported, out of which, 91% (16,604) were
initiated lifelong ART*. During Jan, 2018 to Mar,
2019, around 13,768 HIV exposed live birth were
reported, out of which 11,870 (86.2%) babies were
received ARV prophylaxis.
Scale-up of Pregnant Women tested and positivity in ICTCs
during the period from 2007-08 to 2018-19
(**data (provisional) source is SIMS as on 22nd
Apr., 2019 and the cumulative data since Jan, 2018 to March,
2019 has been taken)
*(CST-MPR Report)
2 2.3
4.6
6.1
6.9
8.4 8.3
9.7
11.7
12.5
16.8
20.7
27.4
0.72
0.65
0.47
0.33
0.25
0.18
0.15
0.12
0.09 0.08
0.05 0.05 0.04
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0
5
10
15
20
25
30
2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 Jan.2018
to Mar
2019
No.
of
women
tested
in
millions
Tested (in Million) % HIV positivity
1. Early Infant Diagnosis (EID)
HIV exposed infants born to infected pregnant
women have to undergo DNA-PCR tests using
Dried Blood Spot (DBS) test (DNA-PCR). During
January, 2018 to March, 2019, about 7,491 babies
(6 weeks to 6 months) were tested under the EID
Programme using DBS DNA PCR, out which
137(1.8%) babies were confirmed HIV positive
31. 479
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under DBS DNA PCR confirmatory test, and 100
(73%) babies were put on ART. Under this period,
5,216 HIV exposed babies (6 weeks to 6 months)
were initiated on CPT.
Total no. of HIV exposed babies who underwent
18-month antibody test was 9,234, among these
babies 399 (4.3%) were diagnosed/confirmed HIV
positive and 356 (89.2%) initiated on Paediatric
ART.
2. Quality Improvement Initiatives under
Basic Services
I. Supervision and Monitoring Mechanism:
Supportive Supervisory visit conducted
by BSD Official to NACP facilities in
Haryana, Punjab and Chandigarh from 7th
& 10th
-12th
July, 2018 to review on ground
implementation of the NACP services. This
visit was aligned with PLHIV-ART Linkage
System (PALS) Training programme
organized by Chandigarh and Haryana
SACS.
II. Quality assurance and EQAS: The
diagnostic services provided through ICTCs
across the country are strictly monitored
by a strong Internal and External Quality
Assurance Scheme (EQAS).
III. Supply Chain Management: A strong
monitoring mechanism for inventory
management is in place. The inventory status
for all commodities at the State, District and
Facility level is monitored on monthly basis
at the National level.
IV. PLHIV-ART Linkage System (PALS):
NACO has implemented PALS in India for
tracking & monitoring of cascade of services
provided to HIVPositive general individuals,
pregnant women and their children. PALS
allow the tracking services provided by
different health facilities at different time
points & geo-locations. All States/UTs
implemented PALS and are reporting data in
it.
V. Community Based Screening approach:
CBS is an important approach for improving
early diagnosis, reaching first-time testers
and people who seldom use clinical services,
including men and adolescents in high-
prevalence settings and HRG populations.
To improve HCTS access and coverage,
community-based HIV screening is carried
out through various approaches such as:-
a) Mobile HCTS;
b) Screening by ancillary health-care
providers (ANC);
c) Screening for HIV by TI (TI-ICTC);
d) HCTS for prison inmates and
e) HCTS at the workplace.
Currently the bulk of CBS efforts are through
targeting HRGs via TIs and Other Development
Partners and CSO.
• In this regards regional ToT were conducted
in different regions to create master pool for
conducting the field level training. NACO
has completed the TOTs and around 2,015
master trainer are trained from all 36 States/
UTs.
• Standard Operating Procedures for CBS
and training manual “Testing through TI”
for Community Based HIV testing under
National HIV Counselling & Testing
Services Guidelines, 2016 has been shared
with all the States.
• As on 2018 December, 1,821 CBS sites
were established under different settings as
mentioned above and reporting to NACP
through SIMS.
• In current financial year approximately 8
lakh Pregnant Women were screened for
HIV through VHND level testing.
• As per the current SIMS Report, 25 States
are implementing CBS. Out of 1,427 TIs,
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ANNUAL REPORT I 2018-19
786 TIs are reporting in SIMS with 4.1lakh
individuals screened since April, 2018, and
there are multiple civil society organizations
having conducted a cumulative of 100,000+
screenings.
VI. Achieving Elimination of Mother to Child
Transmission of HIV (EMTCT):- Every
year, globally, an estimated 10.4 lakh
women living with HIV become pregnant.
Untreated, they have a 15-45% chance of
transmitting the virus to their children during
pregnancy, labour, delivery or breastfeeding.
However, the risk drops to just over 1% if
ARV medicines are given to both mothers
and children at the stages when chances of
transmission can occur. As treatment for
prevention of mother-to-child-transmission
is not 100% effective, elimination of
transmission is defined as a reduction of
transmission to such a low level that it no
longer constitutes a public health problem.
India is signatory for achieving the EMTCT of HIV
and Syphilis by 2020. A road-map for achieving
EMTCT was prepared and has been steadily rolled-
out under the current NACP.
Looking at elimination of MTCT goals, NACO
has conducted the data verification for EMTCT of
HIV & Syphilis in the 6 identified States(phase-1);
Andhra Pradesh, Telangana, Maharashtra,
Tamil Nadu, Karnataka, Mizoram and data
validation in the State of Maharashtra, which
have demonstrated successful implementation &
achievements of EMTCT in our country, based on
certain programme indicators which are outlined
in the global guidelines on criteria and process of
EMTCT verification.
National Workshop on Elimination of Mother to Child Transmission of HIV, October, 2018
National Workshop on Elimination of Mother to Child Transmission of HIV, October, 2018
To accelerate the activities towards EMTCT data
verification exercise in the States, NACO has
initiated the process of data verification in the
identified EMTCT Phase-2 States of the country
(viz. Assam, Bihar, Delhi, Gujarat, Odisha,
Jharkhand, MP, Manipur, Rajasthan, UP, West
Bengal, Punjab and Chandigarh) and (phase-1)
viz. Andhra Pradesh, Telangana, Maharashtra,
Tamil Nadu, Karnataka and Mizoram). EMTCT
assessment activities is going on 19 States (phase-1
& phase-2).
33. 481
CHAPTER-24
VII. Review meetings
As part of program, the BSD, NACO has been
conducting review meetings on BSD components
at regular intervals both at National and State
level, which includes, review meeting for SACS
(ICTC/PPTCT) and STI components, National
TB HIV Joint review meetings, National TB HIV
Coordination committee (NTCC) and, National TB
HIV Technical Working Group (NTWG) meetings.
The main purpose of the meeting is evaluating the
performance of the States/UTs under NACP.
VIII. Training
a) EMTCT Phase 2 State Assessment Leads
(Training of Trainers) along with orientation
of SACS officials in 19 States/UTs held at
Chennai on 26-27 September, 2018. The
2 days training was organized by ICMR-
NIE Chennai. This training was planned
to train the identified resource persons on
the national/state/district/facility level for
EMTCT assessment activities. They will
subsequently conduct the assessments and
train the District Implementation Teams at
the state/regional level. The representatives
from 19 States/UTs, Development Partners
and Officials from NACO attended the
training.
b) So far the progress made regarding the
training of ANM/Staff Nurse and Counsellor
by project Saksham-Prerak of TISS is as
below:
i. ToT of Project Saksham-Prerak Staff
was conducted at TISS, Mumbai from
22nd
to 24th
October, 2018.
ii. All 10 (Chandigarh, Bhubaneswar,
Patna, Lucknow, Imphal, Guwahati,
Chennai, Bhopal, Jaipur and Pune)
Regional Training Units (RTU) and
one NACO PC at Delhi are in place.
iii. The training ofANM & Staff nurses on
HIV & Syphilis screening of pregnant
women has started in December, 2018
and so far we have conducted 34
training batches in 11 States & one UT.
iv. 605 facilities (411 PHCs, 16 CHCs
and 178 other type) covering 968
healthcare service providers (439
ANMs, 270 staff nurses and 259 other
similar profiles).
v. Of these 563 facilities are newly
created FICTCs registered 1st
January,
2018 onwards.
vi. Agency for developing E-learning
platform for virtual training has been
selected and in the same breath TISS
Saksham-Prerak has requested to
support for selection of Consultant to
develop eLearning Module Content.
vii. Around 30 batches covering approx.
30 participants each are planned in
Feb, 2019.
c) E-learning module: With the aim to introduce
innovation in technology and ease of comfort
for counsellors, lab technicians and other
healthcare providers in this journey; NACO,
in collaboration with UNAIDS has captured
theNationalHCTSguidelinesinanengaging,
simplistic, and retainable eLearning module
in Hindi and English languages, to facilitate
smooth scale up, efficient implementation
and uptake of HCTS. With these digitized
learning modules, we aim to empower our
teams, ensure accurate implementation of
the guidelines, and realization of our national
goals with reference to the global SDG’s.
AS&DG (NACO), MoHFW, GOI, launched
the “eLearning Module on HIV Counselling
and Testing Services Guideline” on 26th
October, 2018 during National EMTCT
workshop held on 24th
to 26th
October, 2018
at Hyatt Regency New Delhi.
• The eLearning on HCTS guidelines has been
34. 482
CHAPTER-24
ANNUAL REPORT I 2018-19
rolled out with 25 States and UTs through
“WebEx session” at UNAIDS Office. NACO
is organising regular webinars to facilitate
counsellors and lab technicians in SACS,
DAPCU and ICTC levels to adopt the
digitised trainings.
• More than 800 counsellors joined WebEx
session till December, 2018.
• Around 130 counsellors completed the
course from the State Madhya Pradesh and
received their certificate.
• NACO is continuously requesting State/
UTs to motivate their counsellor to access
the eLearning platform (http://elearninghcts.
org/) and complete certification.
Newer Initiatives:
1. Implementation of E-Learning Module on
HCTS guideline to digitalize the training of
HCTS staff with aim to introduce innovation
in technology and ease of comfort for
counsellors, lab technicians and other
critical partners in this journey, NACO, in
collaboration with UNAIDS has captured the
National HCTS guidelines in an engaging,
simplistic, and retainable eLearning module
in Hindi and English languages, to facilitate
smooth scale up, efficient implementation
and uptake of HCTS.
2. EMTCT Phase –II, State assessment has
been conducted in 19 States (phase II states
via; Assam Bihar Delhi, Gujarat, Odisha
Jharkhand, Madhya Pradesh, Manipur,
Rajasthan, Uttar Pradesh West Bengal,
Punjab, Chandigarh and phase I Andhra
Pradesh, Telangana, Maharashtra Tamil
Nadu, Karnataka and Mizoram).
3. CBS of HIV has been scaled up through TI
project, VHND level screening of PW and
though CSO.
4. BSD-NACO has decided to make paperless
register in all HCTS centers and the
preparatory work has begun since August
2017. E-fountain, an IT firm has been
appointed for developing the e-registers
(software format of Counselling registers
uses in SA-ICTC and F-ICTC) in software
format. Finally, the software for registers
has been developed and piloted in 10 HCTS
facilities (both SA-ICTC &F-ICTC) in Delhi
State.
Way forward:
1. Scaling up of CBS of HIV by 100%
saturation of TI Projects and VHND level
HIV Screening of Pregnant women across
the country.
2. All the State will be oriented on the
eLearning Module by end of March, 2019,
following which all SACS will ensure that
all the counsellors go through the E-learning
module package.
3. Implementation of risk assessment tool in
ICTC for assessing the risk and vulnerability
of self-initiated client to reach first 90.
4. F–ICTC has to start in different OPD of all
the medical colleges, in coordination with
MCI.
5. Implementation of Digitalized ICTC/PPTCT
register with minimum typing content for
counsellor with the support of PATH.
d) HIV/TB Collaborative Activities
TB disease is the commonest opportunistic
infection among HIV-infected individuals. Further
it is also known that, TB being a major public
health problem in India accounts for 25% of deaths
among PLHIV. It is known that nationally about 3%
TB patients registered under the Revised National
Tuberculosis Control Programme (RNTCP) also
have HIV infection. In Manipur and Mizoram
States, HIV positivity among TB patients is more
than 10%. Thus, while the country is dealing
35. 483
CHAPTER-24
effectively with HIV burden, TB associated HIV
epidemic is posing a great challenge.
Broadly the national HIV/TB response includes
activities to reduce burden of HIV among TB
patients and TB among HIV infected individuals.
These activities are closely guided through duly
constituted National HIV-TB Coordination
Committee, National Technical Working Group
and State and District level Coordination
Committees. The NACO and RNTCP have been
successful in increasing access and uptake of HIV
testing and counselling for all TB and presumptive
TB patients.
The objectives of the collaboration are to have
close coordination between RNTCP and NACP at
National, State and District levels & to decrease
morbidity and mortality due to TB among persons
living with HIV/AIDS. The framework adopted a
four-pronged strategy
a. Preventive activities focusing on IPT and
infection control measures
b. Early detection of TB/HIV with the use of
molecular diagnostics
c. Prompt treatment of TB/HIV with FDC,
including test and treat policy for PLHIV
d. Management of TB/HIV cases in special
situations
TB services are provided as a referral service to the
most vulnerable populations which include FSW,
MSM, TG/, IDU and Bridge Populations such as
Migrants and Truckers as part of harm reduction
services. During the routine outreach services, the
Peer Educator and other outreach team member
screen HRGs and bridge populations for TB
symptoms & refer them to the nearest TB centre
for confirmation and treatment. In order to promote
intensified TB case finding at TIs and increasing
awareness and reduce stigma for both TB & HIV,
three different models are proposed based on the
location, and facilities available at TI level. The
models being adopted by the programme are (a)
TB Screening through outreach, (b) Screening of
Presumptive TB cases through RMC&C, (c) TB
Screening at OST centre.
Annual trend of TB-HIV burden for India
(2001-2017)
The co-location of Designated Microscopy Centres
(DMCs) and HIV testing facilities was 85% as on
April 2018. The trend in the Linkage of TB HIV co-
infected patients to CPT and ART is also showing
healthy trend in India. 93% & 89% of co-infected
patients received CPT andART respectively during
2018-19 (till Dec, 2018) whereas 92% & 88% of
TB HIV co-infected patients were linked to CPT
and ART during FY 2017-18.
Intensified TB Case Finding (ICF)
Under ICF, all ICTC clients are screened by ICTC
counsellors for presence of TB symptoms at the
time of pre/post-test counselling. Clients who have
symptoms or signs of TB, irrespective of their
HIV status, are referred to RNTCP diagnostic and
treatment facility located in nearest/co-located
institution. During FY2018-19 (Jan, 18-Mar, 2019)
7.3% (0.6% - 23.6%) of general clients (except
pregnant women) receiving pre-test counselling/
information have been referred for TB testing
from ICTC, and detected total 83,907 TB cases
i.e. 5.3% TB cases out of referred and found 9,851
individuals co-infected with TB and HIV both at
ICTC i.e. 0.6% of total referral.
Patients diagnosed with TB are linked to first
line anti TB drugs daily regimen for TB patients
diagnosed in the respective ART centers. 93%
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ANNUAL REPORT I 2018-19
(8,83,456 out of 9,48,551) PLHIV attending ART
centre were screened for ICF for 4 TB symptoms
at ART centres and subsequently 6% (50,053 out
of 8,83,456) were identified as Presumptive TB
cases & 69% (34,732 out of 50,053) presumptive
TB cases were referred to RNTCP, among whom
85% (29,620 out of 34,732) were tested for TB and
3,444 PLHIVs were diagnosed with TB i.e., 12%
as per monthly ART centre report (MPR-Mar.,
2019).
Isoniazid (INH) Preventive Therapy (IPT):
IPT is one of the strategies globally recommended
for prevention of incident TB among HIV infected
individuals. IPT is a key public health intervention
for the prevention of TB among people living with
HIV. IPT Coverage among eligible PLHIV is 43%
as on March, 2019.
Newer Initiatives:
• Launch of E-Nishchit implementation
of initiative on capacity building of ART
centres using ECHO Platform for HIV TB
on 2nd
April, 2018 at National Institute of
Tuberculosis and Respiratory Diseases
(NITRD), New Delhi.
• Country-wide coverage of policy for HIV
testing among all presumptive TB cases.
• Expansion of TB HIV collaborative activities
in private sector health facilities.
• Nationwide implementation of TB infection
control activities at all ART centers.
• TB active case finding campaign among
HRGs of HIV across various districts of the
country.
Way forward
• Scaling up Provider Initiated HIV testing
and Counselling (PITC) across the country
among Presumptive TB cases and Private
sector TB patients.
• Strengthening IPT implementation
• Assessing feasibility of other innovative
TB prevention therapies like 3 months of
Isoniazid and Rifapentine, 4 months of
Rifampicin as an alternative to 6 months
Isoniazid preventive therapy with INH.
• Strengthening linkages of TB and HIV
patients for nutritional support.
24.7 CARE, SUPPORT AND TREATMENT
TheCare,SupportandTreatment(CST)component
of the NACP aims to improve the survival and
quality of life of Person Living with HIV (PLHIV)
with Universal access to Comprehensive HIV care.
CST services are provided through a spectrum
of service delivery models including ART
Centers (ARTCs), Center of Excellence (CoE),
PaediatricCenters of Excellence (P-CoE), Facility
Integrated ART Centers (FI-ART), Link ART
Centers (LAC), Link ART Plus Centre (LAC Plus)
and Care & Support Centers (CSCs) established
by NACO in health facilities across the country
with aim to provide universal access to free and
comprehensive CST Services. There are active
linkages and referral mechanism for monitoring,
mentoring, decentralization and specialized care.
The CST services includes free universal access to
lifelong standardized ART, free lab diagnostic and
monitoring services (baseline tests, CD4 testing,
targeted VL), facilitating long term retention in
care, prevention, diagnosis and management of
opportunistic Infections and linkages to care and
support services and linkage to social protection
scheme.
Facilities March-2019
ARTCenter 544
Link ART Centers 1108
Care and Support Centers 310
Center of Excellence (CoE) 11
PediatricCoE 07
ART Plus Center 93
PPP-ART 26
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24.7.1 Accomplishments and Learning
A. National Technical Guidelines
Standardized and uniform national technical
guidelines are necessary for standardizing
treatmentpracticesandhenceimprovingthequality
of HIV care across all sectors of health care in our
country context especially when many guidelines
with spectrum of recommendations already exist.
Based on recent developments, the guidelines for
ART were revised. Major focus and inclusions in
the revised guidelines are as follows:
• Focus on National recommendations
• Considering the availability of diagnostic
and treatment options in the country
• Harmonize the treatment practices between
public and private sector since there are
patients seeking care from both sectors
simultaneously or at different point of time
• Consolidate various existing guidelines and
include recommendations for all age groups
and populations
• Provide standardized guidelines for
prophylaxis,prevention,screening,diagnosis
and management of common opportunistic
infections among PLHIV.
B. Improving ART retention
ART retention cascade refers to the sequential steps
of patients from diagnosis of HIV to linkage with
ART care, ART initiation and retention of patients
who are on ART. The retention across the country
has been leveraged up to 75% through CBS, prison
outreach activities, differentiated service delivery
Beneficiaries March-2019
PLHIV on ART 1292938
PLHIV in Preparedness Phase 31579
PLHIV on Second Line 52192
PLHIV on Third Line 2295
CLHIV 75521
Model and Test & Treat policy. Other interventions
such as, quarterly feedback and score card have
also facilitated in improving retention rate.
The major stages in retention cascade are as
following:
• Diagnosis to Registration at Treatment
site: ICTC to ART linkage has increased
from 80% in 2013-14 to 91% in 2017-18.
There are approx. 1,52,000 HIV positive
cases diagnosed at ICTC.
• ART Initiation: The program has achieved
a remarkable improvement in ART initiation
rate from 61% in 2013-14 to 91% in 2018-19.
There are around 1,74,667 new registrations
at ART centre across the country and
1,59,208 new initiations in ART at the end of
the reporting year.
ART initiation
191 184 178 170 172 174
116 121 115 123
150 159
61%
66% 65%
72%
87%
91%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
20
40
60
80
100
120
140
160
180
200
2013-14 2014-15 2015-16 2016-17 2017-18 2018-19
In
Thousands
New Registration at ART centre Initiated on ART % of initiated
12-Month Retention
116 121 115 123
232
80 89
173
70%
72%
75%
0.67
0.68
0.69
0.7
0.71
0.72
0.73
0.74
0.75
0.76
0
50
100
150
200
250
2013-14 2014-15 2015-16 2016-17 2017-18
Thousand
Initiated on ART Retained at 12 month % of Retention
• 12-month retention: The program retains
75% of PLHIV after 12 month of ART
initiation which is a significant achievement
towards the 90-90-90 target. CST division is
closely monitoring retention cascade as quality
indicator at State and facility level. Over the
last three years the program has seen significant
improvement in treatment retention.
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ANNUAL REPORT I 2018-19
C. Mission “SAMPARK”
To extend the benefit of test and treat policy and
reach out to all those “who are aware of their HIV
positive status” but “are not on ART” and linking
them back as much as possible for HIV care, Govt.
of India took the initiative in the form of “Mission
SAMPARK”, launched on 1st
December, 2017.
Under “Mission SAMPARK”, it was planned to
focus on three specific groups:
• 80 New registrations after April, 2017
• Patients in pre-ART care in March, 2017
• Loss to follow-up clients
Two-pronged strategy was adopted for
implementation of this initiative:
A. Data cleaning
B. Outreach
Outcome:
• New registrations after April, 2017:
Between April, 2017 to March, 2018, 1.73 lakh
PLHIV were registered at ART centre out of which
1.51 (87%) have been initiated on ART. In the
current financial year, since April 2018, 1.19 lakh
PLHIV have been registered out of which 1.06
lakh have been already initiated ART by end of
November, 2018 which is 90% of the registration.
• Patients in pre-ART care in March 2017
As per March 2017, 1.85 lakh PLHIV were in pre-
ART care. This category was specifically focused
on counselling and tracking for ART initiation. By
November, 2018, it has decreased to approximately
40,000 (28000 are backlogs and 12000 are newly
registered clients) patients in Pre-ART care.
Out of these 1.85 lakh, 1.2 lakh (65%) already
been initiated on ART. Another 28,000 are under
preparedness and others 37,000 patients (20%)
were lost cases. Intensified efforts are continuing
to bring them back to the treatment.
• Loss to follow-up:
During the drive, line list of more than 4.2 lakh
was received and priority was given to LFU after
2010. Out of which 49,774 LFUs linked back to
HIV care, 31877 LFUs reported died, 20,432
PLHIV who have been contacted but yet not linked
back and are in process of counselling and 236,712
PLHIVs found as untraceable, where addresses
were incorrect or where person has migrated to
other place without providing next address.
D. Differentiated Care
The ARTC infrastructure under the NACP has
expanded from 8 centres in 2004 to 544 centres in
2018.Currently,thenationalHIVprogramprovides
free first line, second line and third line ARVs to
approx.10.3 lakhs. Programme has adopted “Test
and Treat” policy with aim to expand access to
life saving ART and achieve 90-90-90 targets by
2020. With the implementation of the policy, 3
challenges were foreseen;
• Overcrowding at the ART Centers
• Maintaining 12-month retention levels
• Enhancing adherence amongst On-ART
patients
Resolving these 3 challenges is essential to
achieve the target of third 90. Decongesting ART
Centers can help in improving quality of care and
services offered to PLHIV. National Consultations
on ‘Differentiated Care’ was organized with the
objective of seeking inputs from technical experts,
SACS, HIV community and development partners
onkeymodelsandexperiencefromimplementation
of differentiated models across the globe.
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Based on the recommendations, following
differentiated care strategies have been initiated:
¾
¾ Multi-Month Prescription (MMP): 2
months dispensation was already approved
in guidelines, however due to various issues
the access to it was very limited. Country
has started 3-month dispensation for stable
PLHIV since Sep-2018 in phased manner. In
first phase it is limited to people who are on
TLE. App 6 lakh PLHIV are on this regimen.
¾
¾ Intensified Adherence Counselling: As
more than 30% become MIS within first
3 months, it is important to counsel and
follow-up the newly initiated patients during
the first three months specially to help the
PLHIV who might have developed side-
effects due to initiation of ART. Under this
approach, now all newly initiated clients are
being actively followed up by ORW for first
three months to ensure their retention and
adherence during this critical period.
¾
¾ Community Led ART Dispensation: The
ART dispensation for stable clients is now
also available at selected Care & Support
centers managed by PLHIV network as well
as NGOs running TIs for KPs. Currently app
1200 PLHIV are availing these service.
E. End Mile Supply Chain Solution
In order to strengthen national response to AIDS,
NACO with the support of Global Fund has signed
MoU with Plan India (a civil society organization)
for the last mile solution for supply chain
management of all ARV drugs and testing kits.
The last mile solution for Supply chain mechanism
for ARVs and testing kits engages third party
logistics to ensure physical delivery of the
commodities till last facility (ICTC/ARTC). The
project envisions efficient transformation and
coordination of NACO/SACS commodity supply
chain, with good data visibility, in order to ensure
consistent supply and continuous availability of
ARV drugs and Testing Kits at ART and ICTC.
24.7.2 Feedback Mechanism
The ART services have grown many folds since
its launch, through 8 ART centers in 2004 to 544.
These ART centers are providing free treatment to
approx. 12.73 lakh People Living with HIV/AIDS
(PLHA) till date.
Along with quantitative scale up, the division has
been working consistently towards maintaining the
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ANNUAL REPORT I 2018-19
quality of services provided under the programme.
To ensure this, CST division has designed a set of
monitoring and evaluation (M&E) tools namely 1)
Score Card and 2) Quarterly feedback report.
a. Score Card
The tool is developed with an intention to provide
performance status of each ART center on pre-
decided critical indicators in an individual state
at a single glance to the programme managers
at SACS. The performance under the indictors
are denoted by colour coding wherein green
color denotes good performance, yellow as in
average and red denotes the performance deficit.
These scorecards are being sent quarterly to all
the SACS.
b. Quarterly Feedback Report
The report is developed by CST division to provide
feedback on the position of the state’s performance
on the indicators critical in way to achieve the
India’s committed target of 90-90-90 by 2020.
These reports are sent after every three months to
states. As of now all the four quarter’s reports have
been sent. These reports have resulted in bringing
remarkable improvement in ART initiation, drug
adherence, retention and mortality and morbidity
reduction among PLHIV in states during the year
2018.
24.7.3 Annual Review Meeting
The National Review Meeting of the CST division
of NACO was held from 15th
to 17th
January, 2019
at Bhubaneshwar, Odisha. The objective of the
meeting was to review the progress made in CST
programme with focus on new strategies adopted
in last two years - Test & Treat policy, Mission
Sampark and Differentiated Care model and to
address the issues at State level.
CST Division presented the progress made in CST
program (2018) and plan for 2019. It included
the accomplishment and learnings, challenges,
limitations, determinants and road map for 2019.
The data for ICTC- ART linkage, ART initiation
and 12-month retention was presented.
Major topics covered during the technical sessions
were:
